Summary

The aim of injectable bulking agent therapy for SUI is to create coaptation and a mucosal seal for the incompetent urethra. Injectable bulking procedures have the advantages of simplicity, repeatability, and minimal risk of complications. Performed in an outpatient setting under local anesthesia, injection therapy is suitable for first line therapy for SUI,especially in people who are not candidates for surgery requiring regional or general anesthesia, or who cannot discontinue their anticoagulation therapies. Whereas the best candidates for injection therapy were originally thought to be only those with pure ISD and good anatomic support, the indications for its use has been supported for all females with SUI.

Results of the injectable therapy are variable and dependent on the material and route of administration, the number of injections used per session, and the number of sessions needed to achieve a continent status. The definition of successful patient outcomes is not standardized for injectable therapy and the minimum follow-up period reported varies. Despite these issues, the contemporary clinical experience warrants continued enthusiasm for injectable bulking agent therapy as an option for treating female SUI. Clinical research optimizing the reporting of standardized outcome measures, as well as defining the natural history of the condition, will help to clarify the role of this therapy among all the options for the treatment of SUI.

Overall, injectable therapy complication rates are minimal and the severity is usually minor. It is our belief that complications such as extravasation of the implant material are attributable to the injectable material placed using high injectable pressure systems or in cases in which the patient is given a regional or general anesthetic that blocks the ability to report discomfort when the material is implanted too deep into the muscularis wall of the urethra. For these same reasons, prolonged urinary retention may develop when too much material is injected. Thus, ideal techniques, such as the bent-needle approach to periurethral injections, will minimize the risk of the above complications. Furthermore, costs and rare complications caused by regional or general anesthesia for a procedure that can be performed under a local anesthetic support the enthusiasm for adopting the use of techniques that best achieve this goal. As with many minimally invasive therapies for the treatment of SUI, complications seem to be unique to the material used and the technique of application as listed below.

The one major drawback to contemporary injectable therapy is that it may not produce a complete or long-term permanent treatment solution for the SUI condition because we have little knowledge of its various etiologies and respective natural histories. Conversely, one major attraction of this therapy is its perceived advantage in the SUI patient with borderline bladder function such as hypocontractility, requiring a near-reversible solution to their management of complex voiding dysfunction. Frequently, reinjections may be necessary if this option is selected for the management of SUI, and the quest for innovations in injectable therapy continues to support the clinical application and research for discovering potential permanent treatment options for SUI.

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